Archive for December, 2012

I've seen a number of articles in The Wall Street Journal recently discussing the use and misuse of legal pain pills. I had planned to finish this series of blog posts today, but something changed my mind.

The article was gripping, with the UK cost of drug misuse, in three spheres--healthcare, societal and resultant crime--being estimated at 10-16 billion British pounds a year. Looking at the exchange rates for 2007, one can approximately double that number, so we're looking at $20-32 billion/year in the UK alone.

Two expert panels were assembled (one composed of psychiatrists who specialized in addiction) and their results were compared in three areas; physical harm, dependence and social harms. The drugs they were compiling data on were not quite what I expected. In addition to familiar illicit drugs (e.g., heroin, LSD, ecstasy and cocaine), they included khat, a stimulant-containing leaf that is chewed by ~10 million people worldwide (mostly in East Africa and the southwestern portions of the Arabian Peninsula). They also rated methadone and buprenorphine, drugs that are used in combatting withdrawal symptoms in patients being treated for addiction to narcotics.

Benzodiazepines are prescribed for anxiety and insomnia; they are widely used and relatively safe, but certainly can be addicting. Alcohol and tobacco, of course, are available without any doctors prescription.

In recent years we've been repeatedly told of the positive effects of red wine, especially as decreasing the risk of coronary heart disease . A health writer for the Beth Israel Deaconess Medical Center, a Harvard Medical School teaching hospital, published a 2008 review of the subject. The bottom line was 1). there were no randomized controlled studies on the subject; 2). exercise and a well-balanced diet can offer similar health benefits and 3). it's not possible, at this time to accurately predict who will develop alcohol dependence. The final paragraph of the paper said: "If you don't drink, don't start. If you drink excessively, stop. And if you drink moderately, you may continue to raise your glass and proclaim...'to my health!'"

highly addictive and dangerous

The study in The Lancet concluded that the current UK Misuse of Drugs Act (1971 version amended) was insufficient. That Act classifies drugs into three categories from A as the most harmful to C the least. But tobacco and alcohol account for about 90% of drug-related deaths in the UK and aren't on the list. Long-term smoking (over the age of 30) reduces life span by ten years on average. Smoked tobacco is the most addictive commonly used drug was the group's conclusion, with heroin and alcohol somewhat less so. Tobacco is estimated to cause up to 40% of all hospital illness and 60% of drug-related fatalities. Alcohol intoxication often rsults in violent behavior (I see this in our local paper on a regular basis) and is a common cause of auto and other accidents.

In my last post I went through the history of medications used to treat pain and how one of those, originally a trademarked drug, became the terribly addictive, unfortunately popular, street drug, Heroin. Before I discuss controversies in the use of legal pain medicine we need to review some basic pharmacology and physiology.

The term opiate refers to chemicals extracted naturally from the opium plant with the most familiar being morphine and codeine. Opioids, on the other hand, are semi-synthetic derivatives of opium such as oxycodone and hydrocodone. These are controlled drugs, supposedly available only by a doctor's prescription.

In 2004 the FDA issued a statement on an extended release form of oxycodone called OxyContin approving its usage, but cautioning its potential for abuse. In 2009 an FDA panel voted (in a fairly close vote) that two combination pain pills be taken off the market. They were only the tip of the iceberg; there's a host of such mixes of an opioid with standard non-narcotic pain medicine such as acetaminophen (Tylenol) or acetylsalicylic acid (AKA aspirin) or even ibuprofen (Motrin). Oxycodone + acetaminophen is called Percocet and hydocodone + acetaminophen is marketed as Vicodin. A 2012 363-page summary (sic) report from HHS's FDA Center for Drug Evaluation and Research makes it clear that many of the earlier recommendations have still not been implemented.

The International Association for the Study of Pain has a shorter summary of the physiology of pain. I suppose it's intuitively true, but it certainly wasn't my first thought that pain is a protective mechanism. When I burned my hand on a hot stove as a child, I learned to avoid repeating the process (although I confess that hasn't been 100% successful). These days if I turn on a burner on my gas range, I also turn on its built-in light as a warning signal.

There's a part of our nervous system that warns us of pain (Med-speak for this is nociception from the Latin word nocere, to hurt). It's a separate section from the part that tells our brain of a pleasant smell, or a nice taste or other sensations that won't harm us. Some of our nerves end in nociceptors, unspecialized fibers that convert a number of unpleasant, potentially harmful stimuli into signals to our brain that shout (not literally), "Careful there; that's dangerous!" Nerve cell receptors, in simplest terms, are spots for chemicals to latch on to give signals.

In the 1960s and 70s, receptors for opiods were found in parts of the human nervous system. Some endogenous (produced in our bodies) chemicals can also bind there: two kinds of those are dopamine and endorphins.

Endorphins come in 20 or so types, are most commonly released in response to stress or pain and act to reduce our pain perception much as morphine does. In general they are not felt to lead to addiction or dependence (my only quibble with this statement is the "runner's high" as I vividly remember my Nephrology Fellow who ran 10 miles at a time, twice a day; when he got married his wife persuaded him to cut down to ten miles once a day). Eating chocolate, hot chili peppers and having sex can can cause endorphin release and acupuncture, message therapy and meditation are felt to also stimulate the levels of these beneficial chemicals.

pain comes in many different shapes

When our cells are damaged, as in a bad sunburn, our peripheral nociceptors are activated by a variety of chemical substances that the injury produces or releases. At the same time other chemicals are released that dilate blood vessels in the affected area leading to swelling, redness, and a localized warmth. The resultant increase in local blood flow and inflammation itself promote healing and help protect the injured area against infection.

I think that's enough background; next I'll write of problems with pain pills.

I had a total knee replacement nearly twelve years ago. On the Orthopedic ward I was told I could have one or two strong pain pills every 4 to 12 hours depending on how much pain I was experiencing. Since I have a fairly high pain threshold I decided to take the minimum dose, one every twelve hours. I took the first pill, felt considerable relief from the pain, but also felt strange, so I stayed at that dose.

One way to flex & extend after a total knee replacement

Then I ran into a snag. My release from the hospital depended on the degree of flexion I could achieve in the leg with the new knee. Several times a day I was hooked up to a device that gradually bent my leg. It really hurt, but I toughed it out. The nurses and the physical therapists (PT) didn't seem to communicate with each other and I was a bit slow to catch on.

Something finally clicked in my mind. I was hurting enough so the ward staff hadn't set the machines degree of flexion higher. I decided to take two of the pain pills an hour or so before the PT appeared to check my ability to have the leg bent passively.

This time I was in no pain, although I did feel weird.

"You're doing much better today," she said. "I'll tell your doc you can go home tomorrow."

I had been given a strong pain pill, probably oxycodone and they were going to give me a prescription for several weeks worth to take at home. I asked, "Can I have extra strength Tylenol instead?" I repeated that request when I had low back surgery six months later.

Since that time there's been considerable controversy about strong pain medications. The initial question was whether physicians were under-prescribing for patients with severe pain, usually cancer-related, in fear of getting them "hooked" on the drug. Subsequently there have been at least two tidal shifts in how pain medicines are viewed, one urging more treatment of pain including giving the most potent meds for chronic non-malignant pain (CNMP) as well as for cancer patents (who clearly needed to have adequate pain control and weren't always getting it).

Very recently there's been a re-evaluation of the trend. I want to go back to the basics and then follow the timeline of expert opinion that's been expressed on the subject in the last two hundred years. But I'll begin much further back than that.

A 2008 article now available online and authored by staff from the National Development and Research Institutes and from the Department of Pain Medicine and Palliative Care at New York City's Beth Israel Hospital explored the treatment of chronic pain in depth. A few comments from that article surprised me.

a field of opium poppies

In Mesopotamia, nearly 5,500 years ago, Sumerian farmers cultivated a plant called Hul Gil which translates as the "joy plant." We call it the opium poppy. An August 2002 PBS special titled "Bitter Harvest" walks through how this plant is processed into the highly potent street drug, heroin, with at that time 13 million addicts worldwide The United Nations Office on Drugs and Crimes (UNODC) has a 2009 paper online estimating similar numbers. The major alklaloid (a usually colorless, complex and bitter organic chemical) in opium was isolated in 1903 and named morphine (the Greek god of dreams was Morpheus). Then the Bayer company made a chemical from morphine and gave it the brand name Heroin.

Nowadays much of the world's crop of opium poppies is grown in Afghanistan. The 2009 estimate from UNODC was for $60 billion of the worldwide total of $68 billion.

But I've strayed away from my theme, which isn't street drugs, but prescription medications, so I'll stop here and get back to the synthetic opiods in my next post..

I recently found an article in JAMA, the Journal of the American Medical Association, that struck home. I've had both eyes surgically redone, i.e., had cataract surgery on first my left eye, then my right. The first hint was the inability to correct my vision to 20/20. Then I started noting oncoming lights had halos. I got mildly uncomfortable driving at night, but had no major difficulty until some time after my first laser operation. Then I started to note that street signs were hard to read.

Our ophthalmologist at the time reassured me that having a cataract was common and that the surgery would be very helpful.

It certainly was, although my right eye required a brief in-office touch-up after a few months.

Now it's my wife's turn. She's always had incredible vision; even after needing bifocal and then trifocal glasses her far vision corrected to better than 20/20. She had her left eye's cataract done about two years ago and was very happy with the result.

Then about three months ago she started having problems with driving at night. It's time for the right eye to have its turn. I took over the night driving chores and we had no difficulty on our 30-day, 4,000 mile drive to the far northwest and then across British Columbia and most of Alberta. She'll see our new ophthalmologist in a few days.

This is an ocular cataract.

There's lots of background information on the National Eye Institute's (part of the NIH) website (updated from when I first wrote this post) https://nei.nih.gov/health/cataract and a similar website for the UK sent me by a British reader: http://www.lasereyesurgeryhub.co.uk/cataracts/ I'll go through the basics: First a cataract is a change in the lens, the clear part in the front of your eye that you use to focus an image or light on the retina in the back much like you focus a camera. It can develop in one eye or both; roughly 50% of us will have to deal with at least one cataract if we live long enough, as the majority of cataracts occur as part of aging. You may have small cataracts when you are in your 40s and 50s without noticing significant visual loss.

The University of Maryland has a website with cataract risk factors; besides age as the primary risk factor, you may be more prone to developing a cataract if you are diabetic (either type 1 and 2), have excessive sun exposure, are African American, smoke (a pack a day doubles your risk), drink heavily, have a disease treated chronically with corticosteroids (AKA steroids), suffer a physical injury to an eye or even if you are nearsighted. Researchers think a diet rich in antioxidants (e.g., green,leafy vegetables) may help prevent cataracts.

If you have a cataract, your vision will not be as sharp and you may notice things seen change color to a brownish shade

Surgery is the most common treatment for significant cataracts and is regarded as a safe and effective procedure with 90% of patients experiencing improved vision post operatively according to the National Eye Institute.

So what is this leading up to? The JAMA article dated August 1, 2012, is titled "Risk of Fractures Following Cataract Surgery in Medicare Beneficiaries. I was initially puzzled by this, but as I read the article, the actual title, in my opinion, should have been "Reduced Risk of Hip Fractures ..." Clear vision helps prevent falls and in a 5% random sample of Medicare beneficiaries (that meant 1,110,640), 410,809 had cataract surgery. When compared to those who did not, patients undergoing such an operation had a 16% decreased incidence of hip fracture in the following year.

I'm pleased with the results of my own cataract removal surgery. Are you about to have such a procedure?

One of the most dreaded complications of older age is a broken hip.Patients suffering this injury have a 20% chance of dying in the following year and, among survivors, 25% remain in a nursing home for a year or more.

fractured right hip

The Cleveland Clinic website has a two-page article on hip fractures and osteoporosis that mentions a surprising fact: 60% of falls occur in our homes and only 10% in nursing homes or other institutions. If you are 65 or older you have a one third chance of having a fall in any given year. I'm 71 and only a few months younger than my wife so I was quite interested in finding out what we can do to prevent falls and diminish the risk of breaking a hip.

To start with we can single out older women, and particularly Caucasian women as being in the group most likely to have a fall and complications if they do fall. Three fourths of all hip fractures occur in women.That certainly does not leave out us guys or other ethnic groups, but, overall, we're talking about $20 billion being spent each year on the treatment of injuries from and complications of falls. If you start with osteoporosis, as many of elderly women and especially Caucasian do, you are more at risk for a hip fracture if and when you do have a fall.

The CDC article on "Hip Fractures Among Older Adults," says that hip fracture rates in older adults (men over 85 and women over 75) went down significantly between 1990 and 2006 for unknown reasons. Although there were well over a quarter million hospital admission for hip fractures in 2007, there hadn't been the steady increase in that number as had been predicted in 1990.

Why is that? Perhaps it's due to some of the lifestyle and diet changes that some of us have made.

any kind of weight-bearing exercise works, including walking

I started with the CDC's recommendations: exercise regularly (we do so, but don't get enough weight-bearing exercise so we'll start walking more), ask your pharmacist and your personal physician to review your medication list (I had to decrease the dose of my blood pressure pill after losing 30 pounds {deliberately} four years ago), see your eye doctor yearly (we do) and make home safety improvements.

They also mention dietary and supplement changes to ensure you get enough calcium and vitamin D plus getting screened for osteoporosis and treated if necessary. We're on top of that one also.

But safety hazards around the home was well worth reviewing. There's been a tangle of garden hoses on our garage floor for the last few months. I just went into that area, picked up one potential fall-inducer, drained it outside and stored it in our backyard shed. I can think of two more areas that have caused one or the other of us to stumble. We kept the big dog bed in our bedroom for nearly three months after our dog died; that's now in the basement. And there's a pile of give-away "stuff" in the garage; it could be re-evaluated and moved on to a new home or at least moved to allow us to leave the car more safely.

AARP in an online article "New Strategies for Preventing Falls," also mentions tai chi as one modality of balance exercise that may help. We took a introductory class, purchased two posters and two books for home use; it's time to start using them.